Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Tuesday, February 10, 2009

A Shared Roadmap and Vision for Health IT

Today, the chairs of CCHIT, HITSP, and NeHC (AHIC Successor) issued a joint statement of their commitment to work together on the healthcare IT work ahead. I've attached the text of the statement.

I look forward to a very promising future for us all.

IntroductionToday’s economic crisis has highlighted our need for breakthrough improvements in the quality, safety and efficiency of healthcare. The nation’s business competitiveness is threatened by growing healthcare costs, while at the same time our citizens risk losing access to care because of unemployment and the decreasing affordability of coverage. Meanwhile, the quality variations and safety shortfalls in our care system have been well documented.

Health IT is not a panacea for all of these challenges, but it is a critical first step toward addressing many of them. Before we can restructure payment systems to reward quality, we need reliable, near real time data on outcomes. Before we can reward teamwork and collaboration that re-integrates care, we need applications that let clinicians communicate patient information instantly and securely. And in order to reverse the growing burden of chronic diseases, we need online connections that engage individuals in their care and motivate them to make healthier lifestyle choices.

Our current, paper-based health information process wastes hundreds of billions of dollars annually. Transforming this into a streamlined 21st century electronic system will require many components: a conversion to interoperable electronic health records (EHRs) at healthcare facilities, the adoption of online personal health records (PHRs) for individuals, health information organizations that support and connect these systems to allow information sharing, and finally a national health information network that allows instantaneous secure access – always with appropriate consent from the individual -- wherever and whenever their records are needed.

Where we stand today There are hundreds of stakeholders in the development and adoption of interoperable healthcare information technology including consumers, providers, patients, payers, employers, researchers, government agencies, vendors, and standards development organizations. Over the past 20 years, these groups have worked together informally, but until recently there has not been a process to create a single list of priorities or a coordinated project plan. This fragmented approach in many ways mimics the fragmented healthcare delivery system within the US.

In 2004, the Office of the National Coordinator (ONC) within the Department of Health and Human Services (HHS) was established and charged with creating a single strategic plan for all these stakeholders to work together to harmonize healthcare data standards, create architectures for data exchange, document privacy principles, and certify compliant systems which adhere to best practices. Under ONC/HHS guidance, several groups have successfully implemented this work, leading to demonstrable progress in integrating some aspects of healthcare delivery.

An HHS advisory committee, the American Health Information Community (AHIC), prioritized needs and developed harmonized health IT standards for the country based on multi-stakeholder collaboration around a tool known as a “use case.” It produced 3 use cases in 2006, 4 use cases in 2007, 6 use cases in 2008, and a prioritized list of standards gaps to fill in 2009. The successor to AHIC, the National eHealth Collaborative, is a voluntary consensus standards body that extends the strengths of AHIC by enabling broader private sector and consumer representation. It will continue this work by developing and prioritizing initiatives to solve real implementation challenges in the field.

The Healthcare Information Technology Standards Panel (HITSP), a voluntary group of standards experts, received 13 use cases plus a privacy/security standardization request from AHIC. All of these use cases led to unambiguous interoperability specifications that were delivered within 9 months of receiving the request. The standards were chosen by consensus in an open transparent manner with many controversies resolved along the way. At this point, standards for personal health record exchange, laboratories, biosurveillance, medications, quality, emergency first responder access to clinical summary data, home health device monitoring, immunizations, genomic data, hospital to hospital transfers of records including imaging data, public health reporting and patient-provider secure messaging are finished. Consequently, standards are no longer a rate limiting step to data exchange in these cases.

The Certification Commission for Healthcare Information Technology (CCHIT) has certified over 160 electronic health record products based on detailed functional and standards conformance criteria. It has achieved broad industry recognition as the place to develop a roadmap for the features and interoperability requirements to include in the yearly revisions of health care IT products.

Using the harmonized standards, the Nationwide Health Information Network, a pilot initiative of HHS, demonstrated a successful architecture for pushing data between stakeholders, for query/response to pull data, and appropriate security protections. Many of these pilots have become production systems in their localities.

Working together, thousands of volunteer hours in these organizations have led to policy and technology frameworks that have been embraced by several live healthcare exchanges including those at the Social Security Administration, eHealth Connecticut, Keystone Health Information Exchange, Boston Medical Center Ambulatory EMR, Vermont Information Technology Leaders, Inc. (VITL), MA-Share (a statewide data exchange), and Beth Israel Deaconess Medical Center.

New Framework for Collaboration While much has been accomplished, much remains to be done to accelerate adoption and interoperability of health IT. After an 18 month process involving hundreds of stakeholders, the National eHealth Collaborative (NeHC) was created to carry forward this work. NeHC is structured as a voluntary consensus standards body to bring together consumers, the public health community, health care professionals, government, and industry to accelerate health IT adoption by providing a credible and transparent forum to help establish priorities and leverage the value of both the public and private sectors. As a public private partnership, it is able to reach broadly into all sectors of health care, including health professionals, government agencies, health systems, academic medicine, patient advocates, major employers, non-profits, technology providers, and others.

This balancing of interests and expertise is critical to accelerating adoption and would be difficult to replicate in a purely public or purely private sector setting. Past competing interests and priorities within each sector have contributed to the historically low creation and adoption of compatible enabling technologies. By expanding the role of the private sector beyond what was available through a public-driven forum, NeHC can leverage industry resources and best practices—at the same time, assured public sector and consumer participation engenders activities that are transparent and supportive of high-quality, patient-centric coordinated care. The National eHealth Collaborative has refined and expanded the process for establishing priorities developed under AHIC. The National eHealth Collaborative’s goals for the prioritization process are to:

Identify breakthrough strategies to increase interoperability by prioritizing stakeholder-initiated value cases for national action Provide broader stakeholder input into which value cases and interoperability initiatives are pursued Place more emphasis on the value proposition of each proposed set of interoperability initiatives.

Building on experiences with use cases, NeHC has developed the “value case,” a new tool for setting national priorities which describes the utility and projected benefits of an initiative addressing a specific obstacle to achieving interoperability. Value cases may focus on standards harmonization, but may also address other breakthrough strategies for driving interoperability, including model processes (such as a model of the “ideal” care coordination process); best practices (such as incorporation of ePrescribing into provider workflow or managing the communication of results out to the referring physician); and frameworks (such as a service oriented architecture for health information exchange). Each value case includes an assessment of the feasibility of implementing the proposed standard or other construct and the extent of stakeholder commitment required to ensure widespread adoption.

The processes and criteria to efficiently move the value case process forward begins with a national strategy and national call for submission of cases, both from government and the private sector. High level government participation plays a key role in guiding the value case process. As value cases are developed, NeHC will facilitate the appropriate action. If standards harmonization is required, HITSP will be consulted to develop use cases and recommend standards for adoption, or expert panels may be convened to address architectures, best practices, terminologies, or other issues. Once approved by the NeHC Board, outputs will be provided to CCHIT for potential incorporation into certification criteria and as a signal to developers for their product modifications.

Roadmap Given the resources of the proposed stimulus package, our country is poised for great success in healthcare IT. As a nation, we will work together to ensure every patient has a secure, interoperable electronic health record. But what does this mean for patient care?

We will improve the quality of care by coordinating handoffs between providers. No longer will you be asked to fill out the clipboard with the basics of who you are, what medications you take and your existing medical conditions.

Medications will be checked for interactions as they are prescribed. Caregivers will be electronically notified of critical values in lab results and important results on x-rays.

Patients will be able to access their medical records electronically, communicate with their doctors, and use home monitoring devices to coordinate care without a visit to the doctor’s office.

Beyond these improvements in quality, safety, and convenience, the coordination of care will result in better value for our healthcare dollar by minimizing redundancy and waste.

The roadmap for standards harmonization, certification of healthcare IT products, and secure data sharing of medication, laboratory, and clinical summary information is clear. Completing this work is a journey and all our organizations, NeHC, HITSP and CCHIT, are unified to walk that road together.

The momentum created by the close collaboration of all these groups is based on trust, established working relationships and clearly defined roles/responsibilities. Together, they constitute a healthy ecosystem of organizations, each with clear accountability, transparency, and governance to ensure they are all aligned. We are committed to working together to meet the expectations of consumers and other healthcare stakeholders in the future.

VisionThe past four years have seen significant accomplishments, despite the limited funding made available. Beyond the complex mechanics of setting up these activities, what is probably more important has been the development of engagement and trust from stakeholders throughout the health care sector, something that can not be rushed. With the increased funding available in the economic stimulus legislation, we will build on the momentum, trust, and leadership that has already been painstakingly established.

Our vision is one of a 21st century health system in which all health information is electronic, delivered instantly and securely to individuals and their care providers when needed, and capable of analysis for constant improvement and research. With better information upon which to base decisions, the challenging process of health reform can successfully proceed – measuring quality, rewarding value, engaging individuals -- and lead the way to better health for all Americans.

John Tooker, MD, MBA, FACP is the Executive Vice President and Chief Executive Officer of the American College of Physicians (ACP), Chair of the board for the National Committee for Quality Assurance (NCQA), and Chair of the board of the National eHealth Collaborative (NeHC).

This is another immensely important time in healthcare given the impact that we can make with the proper use of information technology. This is will be our legacy, as our forefathers of medicine handed to us the legacy of their meticulous work in anatomy and physiology. We can give to our next generation the tools to provide the right care at the right time.

I typically resist 'non value adding' comments on blogs, but I must make an exception in this case, and thank you for taking the time to share this information.

The potential positive impact is enormous. As an IT management consultant, and, of course, a consumer of health care, I have been frustrated for years by the arcane and inefficient use of information and IT across the healthcare space. I can't think of a segment that could benefit more from a coherent and progressive approach to informatics!

Creating public-private collaborative innovation partnerships in healthcare is hard, but it is indispensable to leveraging the value, resources and best practices of both sectors, establishing a consensus on priorities and accelerating interoperable health care IT adoption.

And, according to Clayton M. Christensen, a Harvard Business School professor who focuses on innovation, the timing for the launch of NeHC’s new framework and forum for collaboration couldn’t be better.

In a December 15, 2008 Wall Street Journal Executive Briefing, Dr. Christensen argued that “One great benefit of the current economic crisis is that it will create pressure to find a real solution to the health-care problem. We really are in an emergency where it's likely that employers and health-care providers are open to completely rethinking some of the basic assumptions that made innovation seem impossible. The breakthrough innovations come when the tension is greatest and the resources are most limited.”

One global obstacle to achieving breakthrough innovation and interoperability is the lack of a standard format and best practice for more efficiently reporting, viewing and sharing the billions of annual diagnostic patient test results. Standardizing and clinically integrating the format and processes used to report all test results is one specific and feasible value case with obvious benefits that should be compelling for all of the major healthcare industry stakeholders. It is one available breakthrough strategy that can provide the tangible savings, efficiency and safety value proposition for physicians, patients, payers, federal and state governments and private employers that could help drive interoperability and more widespread adoption of EHRs, PHRs and HIEs.

From a clinician IT system user perspective, it is encouraging to see NeHC, CHHIT and HITSP starting to cross the "HIT chasm" that was recently described by the National Research Council.

The transformation to a patient-centric, value-driven, coordinated high-quality care American system depends on a collaboration framework that leverages value cases and standards harmonization, and encourages HIT vendor competition and innovation to differentiate their products beyond the requirements of basic certification and make them more attractive to potential customers.

To say honestly, i stumbled onto your blog while googling. What i found was a treasure trove of information, analysis and views from someone who is an authority in the field. This might not be the right place to post this, but i didnt find a better place.

Thanks Dr. Halamka for this wonderful piece of work that you get time to write inspite of your schedule. I will continue to subscribe regularly to your posts as i continue to enrich myself with information on the HC marketspace.

Also i happened to go through your posts. I would like to know your thoughts on IT outsourcing itself1. you have agreed to the fact that Biz.Process outsourcing would go out of market (in your gartner article). would the same be applicable to IT outsourcing too?2. There are so many product vendors in the HIS space. Interoparability is such a big problem, but we are not seeing the same amount of consolidation as in other sectors, your thoughts on this?

I was very excited to come across your blog. I am always looking for examples of individuals that "get it" when it comes to IT. Wow! A HealthCare CIO that is an MD. Your comments and ideas on the future of HealthCare are valuable.

I have measured productivity rates for software development organizations for sometime now. It is clear that those that specialize in healthcare IT and/or have background in healthcare have productivity rates and quality rates 3 to 4 times higher than generalists in healthcare IT.

You and your readers would probably enjoy my new book Reboot! (it is free and online at www.RebootRethink.Com). I point out the value of specialization in IT. Of course, healthcare has understood the value of specialization for sometime.

As the IT industry matures we will see more and more specialization along some industry line. Those that do not specialize will steadily become obsolete.

The bottom line is the healthcare industry is too complex for generalist IT professionals. I do a fair amount of public speaking and I plan on using you and your blog as an example. Who is more valuable to a healthcare organization a CIO that is a doctor or a CIO that was working at a bank last month?

David LongstreetSoftware EconomistDavid@SoftwareMetrics.Comwww.SoftwareMetrics.Com

In a December 15, 2008 Wall Street Journal Executive Briefing, Dr. Christensen argued that “One great benefit of the current economic crisis is that it will create pressure to find a real solution to the health-care problem. We really are in an emergency where it's likely that employers and health-care providers are open to completely rethinking some of the basic assumptions that made innovation seem impossible. The breakthrough innovations come when the tension is greatest and the resources are most limited.”

I believe the way the ARRA funds are targeted to be distributed to individual doctors and hospitals is a miss-guided approach. This approach will only continue and strengthen the major healthcare IT vendors strangle hold on the enterprise market. At several events I have attended recently (OMG/HL7 2009, Gartner Healthcare IT Summit 2009 as examples) the Gartner and other prominent analyst stated that the major vendors have a lock on the market. The bulk of the ARRA funds will most likely go to these major vendors in the enterprise HIT space. This actually rewards these vendors for "locking up" the market, which in turns leads to poor interoperability, vendor lock in, price escalation, lack of innovation, and customer dissatisfaction. None of the money truly goes to innovators of systems that are architected in a way that lowers costs, improves interoperability, rapid development, and high performance web based systems.

SOA, Rich Internet Architecture, standard medical terminology sets, and the adoption of clinical use cases are strategies that can help bring Healthcare IT to where it needs to be. In medical research, grant monies are targeted towards the innovators, not exclusively the established drug and device manufactures. If we tuned a large part of the ARRA money over to new technology companies that could actually move us forward around common frameworks, that could prove much more effective at providing low cost, highly efficient, and flexible EHR/EMRs than pouring money into the major vendors.

I had a conversation with the CTO of a major vendor who's company actually did develop a SOA based enterprise web app and he said that the decision was "killing us!" Now they were actually having to compete with other companies for different clinical modules and functionalities. Their integrated, single solution provider system was no longer necessary as they could integrate with other vendors via standard HL7, SOAP and XML messages. Their customers started saying "no, I'll get my billing app from this other provider [for example]. They do it cheaper and more efficiently than you do."

This illustrates that there is very little, if any, incentive for the major vendors to open up their systems to become truly interoperable. In fact, there is a strong economic disincentive to do so.

While I whole heatedly applaud the goals behind the ARRA incentives, I believe they are targeted to the companies who have really brought us to the current state of HIT adoption, and these monies will only perpetuate and magnify the problems.